Mass Immunization with Inactivated Polio Vaccine in Conflict Zones - Experience from Borno and Yobe States, North-Eastern Nigeria

"Social mobilization activities in security-compromised areas must use a different approach, focusing largely on interpersonal communication, particularly household and community engagement - in a low-profile manner."

This is one of the lessons learned from an 8-day immunisation campaign carried out in June 2014 as part of the Global Polio Eradication Initiative (GPEI) in the conflict-affected states of Borno and Yobe. This campaign was grounded in the belief that the use of Inactivated Polio Vaccine (IPV) in routine immunisation (RI) to replace Oral Polio Vaccine (OPV) is crucial in eradicating polio.

Pre-implementation activities included creation of the IPV campaign committee by the state national polio emergency operation center (EOC), which recruited and trained health workers, organising vaccine supply and logistics, assessed security risks, prepared temporary mobile clinics (health camps), and strategised about social mobilisation. To understand any possible communication risks that could jeopardise acceptance at the community level, the immunisation programme undertook qualitative research in small areas of Borno, Kano, and Cross Rivers. The United Nations Children's Fund (UNICEF) led communication activities and provided drugs for health camps; the World Health Organization (WHO) trained vaccination teams; and Rotary International arranged advocacy activities. The state EOC also conducted 5 days of intensive training for new personnel, which included topics such as interpersonal communication (IPC) skills. The Committee worked to ensure that most of the new recruits came from the settlements in which they would work.

Advocacy and social mobilisation activities included roundtable and one-on-one discussions with local government chairmen, medical professionals, and associations, as well as Muslim public health workers, traditional and religious leaders, and teachers and officials at public and private elementary and Quranic schools. Borno and Yobe state EOCs developed messages and materials based on the results of their qualitative research, undertaken to ensure they would address the key issues from the community. The messages focused on the concerns community members had regarding permissibility of immunisations in Islam. Respected religious leaders who supported polio immunisation engaged other religious leaders to discuss concerns and dispel any myths. A network of polio survivors, volunteer community mobilisers, town announcers, Federation of Muslim Women Associations in Nigeria, and religious focal persons conducted house-to-house visits to encourage immunisation of all who could contract polio or become carriers of the virus and infect others. In addition, Borno and Yobe State EOC conducted a media campaign before and during the immunisation programme. Volunteer community mobilisers disseminated audio and video messages that addressed the safety and importance of IPV and OPV. They used multimedia mobile phones through Bluetooth, radio jingles, mosque and church announcements, and television. On the basis of previous experience, Borno and Yobe EOC specifically designed communication plans to safeguard against untrue negative reports and false rumours that have previously adversely affected the polio programme in Nigeria. As a strategy to reduce vaccine refusal and help address the high burden of other diseases, the local government areas (LGAs) provided free basic health services, including medications.

Conducted in a total of 867 health camps in 9 LGAs in Borno State and 282 in 3 LGAs in Yobe State, the 8-day event involved two parallel campaigns. The OPV age range goal was 0-59 months, while IPV was meant to reach all children aged 14 weeks to 59 months. The supervisors presented data on the actual number of children immunised at daily LGA level review meetings, and participants discussed challenges, possible solutions, and lessons learned. In some instances, this spurred a change of strategy to increase coverage. Given the violence and killings in many LGAs in both Borno and Yobe states, security agents alerted the LGA level authorities and the state EOC and vaccination teams about the safety of settlements and wards for immunisation.

The teams measured immunisation coverage for both IPV and OPV by determining the actual number of children immunised (from a tally sheet analysis), compared with the intended population. The WHO also conducted independent lot quality assurance surveys (LQAS) after the conclusion of the exercise. OPV coverage was 105.1% for Borno and 103.3% for Yobe. IPV coverage was 102.9% for Borno and 99.1% for Yobe. ("Where we describe coverage as greater than 100 per cent, this reflects original underestimates of the target populations.") In Borno state, LQAS showed that the campaign missed from 10-22% of eligible children in 9 LGAs, while in Yobe state's 3 LGAs, surveys showed that fewer than 10% of children were missed.

Due to the security situation, recruitment of a trained health worker to administer IVP can be difficult; it is recommended that future campaigns take this task on at least 2 weeks before the immunisation campaign. Engaging security agencies even more explicitly in the planning and during implementation of the campaign is described here as important to ensure that vaccinators and caregivers are not at risk of attacks.

In short: "A successful campaign and IPV immunization is viable in conflict areas."